Digestive Diseases and Sciences. VoL 36..No. 2 (February 1991). pp. 238-240
CASE REPORT
Ischemic Colitis in a Crack Abuser R U S S E L L D. Y A N G , MD, PhD, M I N W. H A N , MD, and J U S T I N H. M c C A R T H Y , MD, PhD KEY WORDS: endoscopy; colitis; ischemia; cocaine.
Recreational use of cocaine has reached epidemic p r o p o r t i o n s and is associated with myocardial infarction, cardiac arrhythmias, aortic rupture, cereb r o v a s c u l a r accidents, subarachnoid h e m a t o m a s , seizures, and fetal demise (I). Despite widespread usage of cocaine and crack, intestinal ischemia a p p e a r s to be a rare side effect (3, 4). This is the first reported case of intestinal ischemia temporally associated with the inhalation of crack in a young female. Although this patient chronically used alcohol, there is no k n o w n association b e t w e e n alcohol use and intestinal ischemia. CASE R E P O R T A 26-year-old woman chronically imbibed alcohol and intermittently smoked crack for five years. She denied intravenous administration of cocaine and did not use tobacco or take any other medications including oral contraceptives. There was no history of gastrointestinal disease. On the day of admission, she consumed six glasses of wine and smoked an unknown quantity of crack over a 2-h period. Shortly afterwards, she suddenly experienced nausea, vomiting, then crampy abdominal pain followed by massive bloody diarrhea. These symptoms persisted for several hours and she presented to the hospital. On admission, her pulse rate was 76/rain and regular with a blood pressure of 140/88 mm Hg without orthostatic changes. The patient's abdomen was mildly and diffusely tender to deep palpation. There was no rebound or guarding. Rectal examination revealed watery, bloody stool. Rigid proctoscopy was unremarkable, and her pelvic examination was normal. Admission laboratory tests included a hematocrit of 51%, which fell to 41% following intravenous crystaUoid fluid. She had a white cell count of 29,000 with a left shift and normal prothrombin time. A plain film of the abdoManuscript received June 15, 1989; revised manuscript received July 18, 1990; accepted July 19, 1990. From the Departments of Internal Medicine and Pathology, University of Texas Southwestern Medical Center, 5323 Harry Hines Boulevard, Dallas, Texas 75235-8887. Address for reprint requests: Dr. Justin H. McCarthy, Department of Internal Medicine, University of Texas, Southwestern Medical Center, 5323 Harry Hines Boulevard, Dallas, Texas 75235-8887.
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men revealed a nonspecific gas pattern. Stool smear showed many WBCs, RBCs, and no ova and parasites. Clostridium difficile toxin was not detected, and stool cultures grew normal flora. The patient continued to have intermittent abdominal discomfort and two to three bloody semiformed stools per day. On the fourth hospital day, a gastroenterologist was consulted and colonoscopy was performed because of persistent symptoms. Endoscopically, the rectum appeared normal to 15 cm. From 15 to 60 cm, the mucosa was friable with patchy areas of submucosal hemorrhage and erythema (Figure t). Biopsy of the involved mucosa revealed crypt architecture distortion with regenerating glands and fibrosis of the lamina propria consistent with resolving ischemic colitis (Figure 2). Because of the patient's history of ethanol usage, an upper endoscopy was performed. No bleeding source (ie, ulcer disease or varices) were noted. On the fifth hospital day, the patient was discharged with improving symptoms and remains well two months following discharge.
Fig 1. Photograph from colonoscopy showing erythema, inflammation, and superficial hemorrhage in the rectosigmoid colon.
Digestive Diseases and Sciences, Vol. 36, No. 2 (February 1991)
0163-2116/91/0200--0238S06.50/09 1991PlenumPublishingCorporation
ISCHEMIC COLITIS IN A CRACK ABUSER
Fig 2. Photomicrograph of the colonic biopsy revealing crypt architecture distortion with regenerating glands and fibrosis of lamina propria.
DISCUSSION Intestinal ischemia following cocaine usage is rare (1, 3, 4). Only three cases have been reported in the literature (3, 4). In the first two cases, patients orally ingested cocaine and intestinal ischemia was documented by sequential exploratory laparotomies (3). The third case reported intestinal ischemia following intranasal cocaine and heroin administration (4). This is the first reporte d case of intestinal ischemia temporally related to crack usage documented by colonoscopy and biopsy (Figures 1 and 2). The age of the patient and absence of other predisposing factors makes other etiologies such as thrombosis unlikely. Infectious causes were. ruled out with negative cultures of stool and biopsy Samples. There was no evidence of inflammatory bowel disease on biopsy. The patient did drink alcohol, but this did not appear to play a role in this acute episode. In addition, there are no published reports Digestive Diseases and Sciences, Vol. 36, No. 2 (February 1991)
linking alcohol and intestinal ischemia. This case differs from the previous cases since our patient used crack instead of cocaine and administered the crack by inhalation. Cocaine is thought to cause intestinal ischemia through its intense vasoconstrictive effects (5). Cocaine blocks presynaptic reuptake of norepinephfine in alpha receptors of the mesenteric vasculature, thereby enhancing the vasoconstrictive action of the sympathetic nervous system. In our patient, this increased sensitivity to sympathomimetic stimulation probably led to vasoconstriction, which resulted in her ischemic colitis. This case represents a temporal and not a causal association of intestinal ischemia with cocaine administration. However, acute colitis in otherwise healthy individuals without concomitant risk factors for gastrointestinal disease should alert physicians to the possibility of intestinal ischemia following cocaine use.
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YANG ET AL SUMMARY W e report a case o f acute colitis temporally associated with smoking crack. C o l o n o s c o p y revealed a p a t c h y left-sided hemorrhagic inflammation from the rectosigmoid colon to the spleni~ flexure. Biopsy specimens were consistent with resolving ischemic colitis. This entity should be considered in the differential diagnosis o f acute b l o o d y diarrhea in recreational drug users.
2. Schnoll SH. Daghestani AN, Hansen Tr: Cocaine dependence. Resident Staff Physician 30:24-31, 1984 3. Nalbandian H, Sheth N, Dietrich R. Georgiou J: Intestinal ischemia caused by cocaine ingestion: report of two cases. Surgery 97:374-376, 1985 4. Mizrahi S, Laor D, Stamler B: Intestinal ischemia induced by cocaine abuse. Arch Surg 123:394, 1988 5. Ritchie JM, Greene NM: Local anesthetics. In The Pharmacological Basis of Therapeutics. AG Gilman, LS Goodman, TW Rail, F Murad (eds). New York. Macmillan, 1985, pp 309-310
REFERENCES 1. Cregler LL, Mark H: Special report. Medical complications of cocaine abuse. N Engl J Med 315:1495-1500, 1986
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Digestive Diseases and Sciences, Vol. 36, No. 2 (February 1991)
CASE REPORT
Ischemic Colitis in a Crack Abuser R U S S E L L D. Y A N G , MD, PhD, M I N W. H A N , MD, and J U S T I N H. M c C A R T H Y , MD, PhD KEY WORDS: endoscopy; colitis; ischemia; cocaine.
Recreational use of cocaine has reached epidemic p r o p o r t i o n s and is associated with myocardial infarction, cardiac arrhythmias, aortic rupture, cereb r o v a s c u l a r accidents, subarachnoid h e m a t o m a s , seizures, and fetal demise (I). Despite widespread usage of cocaine and crack, intestinal ischemia a p p e a r s to be a rare side effect (3, 4). This is the first reported case of intestinal ischemia temporally associated with the inhalation of crack in a young female. Although this patient chronically used alcohol, there is no k n o w n association b e t w e e n alcohol use and intestinal ischemia. CASE R E P O R T A 26-year-old woman chronically imbibed alcohol and intermittently smoked crack for five years. She denied intravenous administration of cocaine and did not use tobacco or take any other medications including oral contraceptives. There was no history of gastrointestinal disease. On the day of admission, she consumed six glasses of wine and smoked an unknown quantity of crack over a 2-h period. Shortly afterwards, she suddenly experienced nausea, vomiting, then crampy abdominal pain followed by massive bloody diarrhea. These symptoms persisted for several hours and she presented to the hospital. On admission, her pulse rate was 76/rain and regular with a blood pressure of 140/88 mm Hg without orthostatic changes. The patient's abdomen was mildly and diffusely tender to deep palpation. There was no rebound or guarding. Rectal examination revealed watery, bloody stool. Rigid proctoscopy was unremarkable, and her pelvic examination was normal. Admission laboratory tests included a hematocrit of 51%, which fell to 41% following intravenous crystaUoid fluid. She had a white cell count of 29,000 with a left shift and normal prothrombin time. A plain film of the abdoManuscript received June 15, 1989; revised manuscript received July 18, 1990; accepted July 19, 1990. From the Departments of Internal Medicine and Pathology, University of Texas Southwestern Medical Center, 5323 Harry Hines Boulevard, Dallas, Texas 75235-8887. Address for reprint requests: Dr. Justin H. McCarthy, Department of Internal Medicine, University of Texas, Southwestern Medical Center, 5323 Harry Hines Boulevard, Dallas, Texas 75235-8887.
238
men revealed a nonspecific gas pattern. Stool smear showed many WBCs, RBCs, and no ova and parasites. Clostridium difficile toxin was not detected, and stool cultures grew normal flora. The patient continued to have intermittent abdominal discomfort and two to three bloody semiformed stools per day. On the fourth hospital day, a gastroenterologist was consulted and colonoscopy was performed because of persistent symptoms. Endoscopically, the rectum appeared normal to 15 cm. From 15 to 60 cm, the mucosa was friable with patchy areas of submucosal hemorrhage and erythema (Figure t). Biopsy of the involved mucosa revealed crypt architecture distortion with regenerating glands and fibrosis of the lamina propria consistent with resolving ischemic colitis (Figure 2). Because of the patient's history of ethanol usage, an upper endoscopy was performed. No bleeding source (ie, ulcer disease or varices) were noted. On the fifth hospital day, the patient was discharged with improving symptoms and remains well two months following discharge.
Fig 1. Photograph from colonoscopy showing erythema, inflammation, and superficial hemorrhage in the rectosigmoid colon.
Digestive Diseases and Sciences, Vol. 36, No. 2 (February 1991)
0163-2116/91/0200--0238S06.50/09 1991PlenumPublishingCorporation
ISCHEMIC COLITIS IN A CRACK ABUSER
Fig 2. Photomicrograph of the colonic biopsy revealing crypt architecture distortion with regenerating glands and fibrosis of lamina propria.
DISCUSSION Intestinal ischemia following cocaine usage is rare (1, 3, 4). Only three cases have been reported in the literature (3, 4). In the first two cases, patients orally ingested cocaine and intestinal ischemia was documented by sequential exploratory laparotomies (3). The third case reported intestinal ischemia following intranasal cocaine and heroin administration (4). This is the first reporte d case of intestinal ischemia temporally related to crack usage documented by colonoscopy and biopsy (Figures 1 and 2). The age of the patient and absence of other predisposing factors makes other etiologies such as thrombosis unlikely. Infectious causes were. ruled out with negative cultures of stool and biopsy Samples. There was no evidence of inflammatory bowel disease on biopsy. The patient did drink alcohol, but this did not appear to play a role in this acute episode. In addition, there are no published reports Digestive Diseases and Sciences, Vol. 36, No. 2 (February 1991)
linking alcohol and intestinal ischemia. This case differs from the previous cases since our patient used crack instead of cocaine and administered the crack by inhalation. Cocaine is thought to cause intestinal ischemia through its intense vasoconstrictive effects (5). Cocaine blocks presynaptic reuptake of norepinephfine in alpha receptors of the mesenteric vasculature, thereby enhancing the vasoconstrictive action of the sympathetic nervous system. In our patient, this increased sensitivity to sympathomimetic stimulation probably led to vasoconstriction, which resulted in her ischemic colitis. This case represents a temporal and not a causal association of intestinal ischemia with cocaine administration. However, acute colitis in otherwise healthy individuals without concomitant risk factors for gastrointestinal disease should alert physicians to the possibility of intestinal ischemia following cocaine use.
239
YANG ET AL SUMMARY W e report a case o f acute colitis temporally associated with smoking crack. C o l o n o s c o p y revealed a p a t c h y left-sided hemorrhagic inflammation from the rectosigmoid colon to the spleni~ flexure. Biopsy specimens were consistent with resolving ischemic colitis. This entity should be considered in the differential diagnosis o f acute b l o o d y diarrhea in recreational drug users.
2. Schnoll SH. Daghestani AN, Hansen Tr: Cocaine dependence. Resident Staff Physician 30:24-31, 1984 3. Nalbandian H, Sheth N, Dietrich R. Georgiou J: Intestinal ischemia caused by cocaine ingestion: report of two cases. Surgery 97:374-376, 1985 4. Mizrahi S, Laor D, Stamler B: Intestinal ischemia induced by cocaine abuse. Arch Surg 123:394, 1988 5. Ritchie JM, Greene NM: Local anesthetics. In The Pharmacological Basis of Therapeutics. AG Gilman, LS Goodman, TW Rail, F Murad (eds). New York. Macmillan, 1985, pp 309-310
REFERENCES 1. Cregler LL, Mark H: Special report. Medical complications of cocaine abuse. N Engl J Med 315:1495-1500, 1986
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Digestive Diseases and Sciences, Vol. 36, No. 2 (February 1991)
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